Healthcare Provider Details

I. General information

NPI: 1124064894
Provider Name (Legal Business Name): SOUTHCENTRAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 DIPLOMACY DR STE 1500
ANCHORAGE AK
99508-5925
US

IV. Provider business mailing address

PO BOX 35198
SEATTLE WA
98124-5198
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number20467
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20467
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: RONALD LEE OLSON
Title or Position: EXECUTIVE VICE PRESIDENT FINANCE
Credential:
Phone: 907-729-4939